March 2022 Texas Dental Journal

March 2022

TEXAS DENTAL

INSIDE:

C. difficile:

An Update for Dentistry

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Texas Dental Journal | Vol 139 | No. 3

Compliance & Supplies

Brush up on oral health best practices.

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ASSESSMENTS, EDUCATION AND PREVENTION: 1.25 CE Credit

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Contents March 2022 Established February 1883 n Vol 139, No. 3

FEATURES 120 | C. difficile: An Update for Dentistry Hillary Bui, BS Sydney Pham, BSA Andrew Roberts, BBA Mason Tobola, BS Jayme Witek, BS Arthur Jeske, PhD, DMD C. difficile infection (CDI) is a potential complication of antibiotic

Texas bluebonnet from above

therapy, and while frequently associated with regimens of clindamycin, it is known to occur with any antibiotic. As such, practitioners should be aware of the signs and symptoms of CDI and the potential severity of the disorder, which may lead to death if not promptly and effectively managed.

DEPARTMENTS

143 | Oral and Maxillofacial

108 | President’s Message

Month Diagnosis and

111 | TDA Governance: Officia Call for Nominations 114 | TDA Governance: Official Call to the 2022 Texas Dental Association House of Delegates 116 | Oral and Maxillofacial

Pathology Case of the Management 146 | Value for Your Profession: Email Cybersecurity is Critical for Your Practice—Know How to Protect Your Office 149 | Calendar of Events

Pathology Case of the Month

TDA members, use your smartphone to scan this QR Code and access the online Texas Dental Journal.

104

134 | TDA Governance: Texas Dental Association 2022 Financial Report, 2023 Proposed Budget

Texas Dental Journal | Vol 139 | No. 3

150 | Advertising Briefs 159 | Index to Advertisers

Editorial Staff Daniel L. Jones, DDS, PhD, Editor Paras B. Patel, DDS, Associate Editor Nicole Scott, Managing Editor Barbara Donovan, Art Director Lee Ann Johnson, CAE, Director of Member Services

Editorial Advisory Board Ronald C. Auvenshine, DDS, PhD Barry K. Bartee, DDS, MD Patricia L. Blanton, DDS, PhD William C. Bone, DDS Phillip M. Campbell, DDS, MSD Michaell A. Huber, DDS Arthur H. Jeske, DMD, PhD Larry D. Jones, DDS Paul A. Kennedy Jr, DDS, MS Scott R. Makins, DDS, MS Daniel Perez, DDS William F. Wathen, DMD Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS

The Texas Dental Journal is a peer-reviewed publication.

Texas Dental Association 1946 S IH-35 Ste 400, Austin, TX 78704-3698 Phone: 512-443-3675 • FAX: 512-443-3031 Email: tda@tda.org • Website: www.tda.org Texas Dental Journal (ISSN 0040-4284) is published monthly (one issue will be a directory issue), by the Texas Dental Association, 1946 S IH-35, Austin, TX, 787043698, 512-443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35, Austin, TX 78704. Copyright 2022 Texas Dental Association. All rights reserved.

Annual subscriptions: Texas Dental Association members $17. In-state ADA Affiliated $49.50 + tax, Out-of-state ADA Affiliated $49.50. In-state Non-ADA Affiliated $82.50 + tax, Out-of-state Non-ADA Affiliated $82.50. Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 NonADA Affiliated. For in-state orders, add 8.25% sales tax.

Contributions: Manuscripts and news items of interest to the membership of the society are solicited. Electronic submissions are required. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association.

Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles.

Advertisements: Publication of advertisements in this journal does not constitute a guarantee or endorsement by the Association of Association of the quality of value of Dental Editors and such product or of the claims made of Journalists. it by its manufacturer.

Board of Directors PRESIDENT Debrah J. Worsham, DDS 936-598-2626, worshamdds@sbcglobal.net PRESIDENT-ELECT Duc “Duke” M. Ho, DDS 281-395-2112, ducmho@sbcglobal.net PAST PRESIDENT Jacqueline M. Plemons, DDS, MS 214-369-8585, drplemons@yahoo.com VICE PRESIDENT, NORTHEAST Carmen P. Smith, DDS 214-503-6776, drprincele@gmail.com VICE PRESIDENT, SOUTHEAST Georganne P. McCandless, DDS 281-516-2700, gmccandl@yahoo.com VICE PRESIDENT, SOUTHWEST J. Ted Thompson, DDS 361-242-3151, tedito@aol.com 817-238-6450, pdalw@yahoo.com VICE PRESIDENT, NORTHWEST E. Dale Martin, DDS SENIOR DIRECTOR, NORTHEAST Elizabeth S. Goldman, DDS 214-585-0268, texasredbuddental@gmail.com SENIOR DIRECTOR, SOUTHEAST Glenda G. Owen, DDS 713-622-2248, dr.owen@owendds.com SENIOR DIRECTOR, SOUTHWEST Carlos Cruz, DDS 956-627-3556, ccruzdds@hotmail.com SENIOR DIRECTOR, NORTHWEST Teri B. Lovelace, DDS 325-695-1131, lovelace27@icloud.com DIRECTOR, NORTHEAST Jodi D. Danna, DDS 972-377-7800, jodidds1@gmail.com DIRECTOR, SOUTHEAST Shailee J. Gupta, DDS 512-879-6225, sgupta@stdavidsfoundation.org DIRECTOR, SOUTHWEST Richard M. Potter, DDS 210-673-9051, rnpotter@att.net DIRECTOR, NORTHWEST Summer Ketron Roark, DDS 806-793-3556, summerketron@gmail.com SECRETARY-TREASURER* Cody C. Graves, DDS 325-648-2251, drc@centex.net SPEAKER OF THE HOUSE* John W. Baucum III, DDS 361-855-3900, jbaucum3@gmail.com PARLIAMENTARIAN** Glen D. Hall, DDS 325-698-7560, abdent78@gmail.com EDITOR** Daniel L. Jones, DDS, PhD 214-828-8350, editor@tda.org LEGAL COUNSEL Carl R. Galant William H. Bingham, Advisor *Non-voting member **Non-voting attendee

www.tda.org | March 2022

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OUR MISSION STATEMENT: To provide affordable, quality anesthesia education with knowledgeable and experienced instructors, both in a clinical and academic manner while being a valuable resource to the practitioner after the programs. Courses are designed to meet the needs of the dental profession at all levels.

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Texas Dental Journal | Vol 139 | No. 3

CELEBRATING 30 YEARS

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| March 2022

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Chewon this

Women’s History Month

I

n 1980, the week of March 8 was declared by then President Jimmy Carter to be National Women’s History Week.

This recognition was renewed by later presidents until 1987, when Congress designated March as “Women’s History Month.”

At a recent TDA Board meeting, I was reminded of the achievements, courage, and perseverance that women have similarly made in the profession of dentistry. For the first time in TDA history, the women on the TDA Board outnumber their male counterparts.

As we take time to recognize and honor the growing diversity within the TDA, I would first like to honor the women who helped lay the foundation for myself and for countless others within the profession. Their contribution to the dental profession is invaluable.

Emeline Roberts Jones, a New England native, married dentist Daniel

Jones in 1854 at the age of 18. Jones believed that women were not suited for the profession because of their “frail and clumsy fingers.” Emeline began to secretly study dentistry.

After she had filled and extracted several hundred teeth, her husband allowed her to practice with him.

At the time she was just 19. At the age of 23, she became his partner. She eventually took over the practice when her husband died in 1865. Emeline traveled around Connecticut and Rhode Island before settling in New Haven. She practiced for 6 decades and in 1914 was made an honorary member of the National Dental Association.

While Emeline Roberts Jones was the first woman to practice dentistry, it wasn’t until 1866 that the first woman, Lucy Hobbs Taylor, earned her DDS at age 33. Dr Taylor and her 9 siblings were orphaned when she was just 12 years old and she spent much of her childhood supporting her family by working as a seamstress.

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Emeline Roberts Jones

Dr Lucy Hobbs Taylor

Dr Ida Gray

Dr Leonie von Meusebach–Zesch Photos courtesy of Wikipedia Creative Commons

She still devoted time to her education and moved to Michigan where she taught for 10 years. Because of her gender, Dr Taylor was denied entry into the medical college to which she applied. Not taking no for an answer, she went directly to the faculty and a supervisor from Eclectic Medical College agreed to tutor her. From there she applied to the Ohio College of Dentistry but was refused admission again.

However, Dr Jonathan Taft of the Ohio College of Dentistry, agreed to tutor Lucy.

Eventually Dr Taylor opened her own practice in Cincinnati in 1861, and finally, 7 years after she had begun her dental studies, she received her DDS degree in 1866 through the Ohio College of Dental Surgery. Dr Taylor met her husband the following year and her love for dentistry was contagious! She convinced him to pursue his degree and the pair practiced for another 20 years. By 1900, nearly 1,000 women followed in Lucy Taylor’s footsteps as they began a

career in dentistry.

Ida Gray, the first AfricanAmerican dentist, (also referred to as Ida Gray Rollins or Ida Gray Nelson) grew up an orphan much like Lucy Hobbs Taylor.

Overcoming an unfortunate childhood, Dr Gray was also tutored by Dr Jonathan Taft when she began working in his office while studying at Gaines High School in Chicago. She gained enough knowledge to enter the University of Michigan School of Dentistry in 1887 and graduated in 1890.

While Dr Gray grew up attending a segregated school, she became famous first in Cincinnati for seeing both Black and white patients. When she began to practice in Chicago, she inspired one of her patients, Olive M. Henderson, to become the city’s second Black female dentist.

Dr Gray’s passion about civic matters was as strong as her passion for dentistry.

She was the vice president of the Professional Women’s Club of Chicago, the vice president of the Eighth Regiment Ladies’ Auxiliary, and she was a member

TDA President Debrah J. Worsham, DDS

of the Phyllis Wheatley Club (a group that worked to maintain the only Black women’s center in Chicago).

In the late 1800s and early 1900s, female dentists were becoming influencers both in the field of dentistry and in their communities.

Dr Leonie von Meusebach– Zesch’s impacted the lives of those affected by the San Francisco earthquake of 1906, the Great Depression, and beyond.

In 1902, she earned her DDS from the San Francisco College of Physicians and Surgeons. Leonie began as a dentist’s assistant but soon forged her own dental career path, leaving a legacy that spanned Texas to Alaska.

Following the devastating San Francisco earthquake, Dr Meusebach-Zesch became a dental surgeon with the U.S. Army and www.tda.org www.tda.org || March March 2022 2022

109 109

treated earthquake refugees with her mother helping her document survivors as a volunteer with the Red Cross.

Following the earthquake recovery efforts, Dr Meusebach-Zesch went into private practice and worked as a dentist in the San Francisco Children’s Hospital and in the Maria Kipp Orphanage.

In 1912, she began to hold mobile dental clinics out of her Model T Ford in the state of Arizona, treating all school children free of charge. After moving to Alaska in 1915, she often traveled using a dog sled to reach patients. Returning to California in 1930, with the Great Depression in full swing, she joined the Unemployed Exchange

Association and offered dental services on a barter basis. Dr Meusebach-Zesch also donated services to unemployment camps and school children. In 1937 she became the dentist for the California Institute for Women where she taught female inmates to assist. She also worked with migrant laborers and convict labor camps. If her life sounds amazing, that’s because it was!

One thing these women all had in common was determination and perseverance and most had mentors who influenced their careers. I challenge each of you to take the time to mentor a predental student, dental student, or new dentist. The impact could last for decades!

Finally, the National Women’s History Alliance designates a yearly theme for women’s history month and the theme for 2022 is “women providing healing, promoting hope.” According to the group this is “both a tribute to the ceaseless work of caregivers and frontline workers during this ongoing pandemic and also a recognition of the thousands of ways that women of all cultures have provided both healing and hope throughout history.” I’d like to take this opportunity to thank all of the women on the frontlines of healthcare during the last two and half years for their contribution to women’s history.

Female Dentists Make TDA History

For the first time in TDA history, female members of the TDA Board outnumber their male counterparts.

Picture are the most recent TDA Board meeting are (L-R) Dr Georganne McCandless, Dr Carmen Smith, Dr Glenda Owen, Dr Shailee Gupta, Immediate Past President Dr Jacqueline Plemons, President Dr Debrah Worsham, Executive Director Linda Brady, Dr Jodi Danna, Dr Summer Roark, Dr Teri Lovelace and Dr Elizabeth Goldman.

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OFFICIAL CALL FOR NOMINATIONS OFFICIAL CALL FOR CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS: SPEAKER OF THE HOUSE, SECRETARY-TREASURER, AND EDITOR OFFICIAL CALL FOR SPEAKER OF THE HOUSE CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS Candidacy announcements for the statewide elective office of Texas Dental Association (TDA) Speaker of the House may be submitted to TDA Secretary-Treasurer Dr Cody C Graves for the upcoming 2021 House elections. Only an active, life, or retired member in good standing of this Association shall be eligible. A curriculum vitae (CV) must be submitted, and the candidate will also have to sign a conflict of interest statement. Nominations are in order at the first meeting of the House of Delegates and remain open until the close of the second meeting of the House of Delegates; however, announcements of candidacy should be made as early as possible so that membership eligibility can be verified. To become a nominee, a delegate must place the name of the candidate in nomination at the first meeting of the House of Delegates. Please see the Manual on Caucus, Campaigns, Nominations and Elections at tda.org for full details.

Duties of the Speaker of the House are enumerated in the Bylaws and include the following: 1. To serve as an ex-officio member of the Board of Directors without vote or the privilege of proposing resolutions.

2. To serve as an ex-officio member of the Executive Committee without vote or the privilege of proposing resolutions.

3. To preside at all meetings of the House of Delegates.

4. To determine the order of business for all meetings, subject to the approval of the House of Delegates, in accordance with

Section 140B of this chapter.

5. To appoint tellers to assist him/her in determining the result of any action taken by vote.

6. To appoint members of reference committees in consultation with the president, president-elect, and the immediate past president by the Board of Directors’ first meeting of the calendar year.

7. To notify the divisional officers and the Committee on Credentials, Rules and Order, prior to the annual session, the number of delegates and alternates necessary to constitute a quorum.

8. To meet with the divisional officers prior to the meeting of the divisional caucuses at the annual session to review the Rules for Caucus Procedures, Nominations, And Elections.

9. To appoint a parliamentarian pro tem, should it become necessary for the parliamentarian to be absent during a session of the House of Delegates.

10. To serve as presiding officer of the TDA Candidates Forum, unless the Speaker is in a contested race, at which time the Speaker Pro-tem will preside.

11. To be a certified parliamentarian or be in the process of certification Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Cody C Graves, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704; or, emailed to TDA Executive Director Linda Brady: lbrady@tda.org.

(See TDA Bylaws, Chapter IV, House of Delegates—Sections 100 (Officers), 110A (Duties), 150C(3), 150D, Chapter V, Board of Directors—Sections 10 (Composition); TDA House Manual; Speaker Manual).

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OFFICIAL CALL FOR SECRETARY-TREASURER CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS Candidacy announcements for the statewide elective office of Texas Dental Association (TDA) Secretary-Treasurer may be submitted to TDA Secretary-Treasurer Dr Cody C Graves for the upcoming 2021 House elections. Only an active, life, or retired member in good standing of this Association shall be eligible. A curriculum vitae (CV) must be submitted, and the candidate will also have to sign a conflict of interest statement.

Nominations are in order at the first meeting of the House of Delegates and remain open until the close of nominations at the end of the second meeting of the House of Delegates; however, announcements of candidacy should be made as early as possible so that membership eligibility can be verified. To become a nominee, a delegate must place the name of the candidate in nomination at the first meeting of the House of Delegates. Please see the Manual on Caucus, Campaigns, Nominations and Elections at tda.org for full details.

Duties of the TDA Secretary-Treasurer are enumerated in the Bylaws and include the following: 1. Serve as chair, without vote, of the Budget, Assets and Finance Committee.

2. Examine the income and expenses of this Association and report at each meeting of the Board of Directors.

3. Ensure that the minutes of the House of Delegates and the Board of Directors be maintained.

4. To be responsible and perform such other duties as shall be specified by the Board of Directors and the Bylaws.

Other duties as Secretary include the following: • Serve as recording officer and custodian of the records of the House of Delegates and the Board of Directors.

• Serve as secretary to the Executive Committee, without the right to vote.

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• •

Serve as secretary to the House of Delegates.

Serve as the secretary of the American Dental Association Fifteenth Trustee District Delegation.

Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Cody C Graves, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704; or, emailed to TDA Executive Director Linda Brady: lbrady@tda.org.

(Ref. TDA Bylaws, Chapter IV, House of Delegates—Sections 70A-B (Notice and Publication—Official Call & Publication of Actions, 110B (Duties); Chapter V, Board of Directors —Sections 10 (Composition), 80B (Officers-Secretary); Chapter VI, Elective Officers—Section 90G (Duties); Chapter VIII, Fifteenth Trustee District American Dental Association Delegates and Alternate Delegates—Section 80 (Delegation Secretary); Board Manual; Secretary-Treasurer Manual).

OFFICIAL CALL FOR EDITOR CANDIDACY ANNOUNCEMENTS AND SUBSEQUENT NOMINATIONS Candidacy announcements for the statewide elective office of Texas Dental Association (TDA) Editor may be submitted to TDA SecretaryTreasurer Dr Cody C Graves for the upcoming 2021 House elections. Only an active, life, or retired member in good standing of this Association shall be eligible. A curriculum vitae (CV) must be submitted, and the candidate will also have to sign a conflict of interest statement. Nominations are in order at the first meeting of the House of Delegates and remain open until the close of nominations at the end of the second meeting of the House of Delegates; however, announcements of candidacy should be made as early as possible so that membership eligibility can be verified.

To become a nominee, a delegate must place the name of the candidate in nomination at the first meeting of the House of Delegates.

Please see the Manual on Caucus, Campaigns,

Nominations and Elections at tda.org for full details.

Duties of the editor are enumerated in the Bylaws and include the following: 1. To be editor-in-chief of all journals and publications of the Association and exercise full editorial control over such publications, subject only to policies established by the House of Delegates, Board of Directors, and these Bylaws and provided such content is not in conflict with or contrary to the TDA’s established policies, legislative agenda, or advocacy efforts.

2. To control the selection of scientific material published in the Journal. The editor may appoint associate editors, with the concurrence of the Board of Directors, to gather and/or review material for publication. Such associate editors shall serve as long as the editor deems necessary; but never longer than the term of the editor.

3. To attend all open meetings of the Board of Directors and the House of Delegates of this association, and the annual session of the American Dental Association.

4. To hold no other elective office in this association or the American Dental Association while serving as editor, except the editor may be elected as delegate or alternate delegate to the ADA House of Delegates from his/her respective division.

5. To cooperate with his/her successor upon termination of the Editor’s term of office.

Should the position of Editor become vacant ad interim, the Board of Directors shall appoint an Editor to act in the vacated position until such time as an Editor is nominated and elected in accordance with Chapter V, Sections 40B,b and Chapter IV, Sections 30B,b and 150 of these Bylaws.

Candidacy announcements are to be mailed to TDA Secretary-Treasurer Dr Cody C Graves, Texas Dental Association, 1946 S IH-35 Ste 400, Austin, Texas 78704; or, emailed to TDA Executive Director Linda Brady: lbrady@tda.org.

JKJ Pathology Oral Pathology Laboratory

John E Kacher, DDS • Available for consultation by phone or email • Color histology images on all reports • Expedited specimen shipping with tracking numbers • Reports available online through secure web interface

Professional, reliable service with hightechnology solutions so that you can better serve your patients.

Call or email for free kits or consultation. jkjpathology.com 281-292-7954 (T) 281-292-7372 (F) johnkacher@jkjpathology.com

Protecting your patients, limiting your liability

(Ref. TDA Bylaws, Chapter VI, Elective Officers —Section 90I (Duties); Policy Manual). www.tda.org | March 2022

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OFFICIAL CALL TO THE 2022 TEXAS DENTAL ASSOCIATION HOUSE OF DELEGATES HOUSE OF DELEGATES:

REFERENCE COMMITTEE HEARINGS:

In accordance with Chapter IV, Section 70, paragraph

Reference Committee

A-1 of the Texas Dental

hearings will be facilitated

Association (TDA) Bylaws,

on Thursday, May 5, 2022

this is the official call for the

open to all members who

152nd Annual Session of

are present (any changes

the Texas Dental Association

to committee start times

House of Delegates. All

will be posted on the TDA

sessions of the House

website and announced

will be in the Lost Pines

at the first meeting of the

Ballroom of the Hyatt

House of Delegates):

Regency Lost Pines, Bastrop, Texas. The

10:00 AM

opening session of the House will convene at 8:00 a.m. on Thursday, May 5, 2022. The second meeting of the House will be at 1:30

REFERENCE COMMITTEES A & B (COMBINED) LOST PINES 1

p.m. on Friday, May 6, 2022. The third meeting of

COMMITTEE A:

the House will be at 8:00

Administration, Budget,

a.m. on Saturday, May 7,

Building, House of

2022, followed by the fourth

Delegates, Membership

meeting at 1:30 p.m. until

Processing

close of business.

Component Societies are urged to certify an accurate list of Delegates and Alternates to fill each of their seats on the floor of the TDA House of

COMMITTEE B: President’s Address, Miscellaneous Matters, Component Societies, Subsidiaries, Strategic Planning, Annual Session

Delegates.

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1:00 PM REFERENCE COMMITTEES C & D (COMBINED) LOST PINES 2 COMMITTEE C: Dental Education, Dental Economics, Health and Dental Care Programs COMMITTEE D: Legislative, Legal and Governmental Affairs

3:30 PM REFERENCE COMMITTEE E: Constitution, Bylaws, Ethics & Peer Review LOST PINES 3 The agendas for these committee meetings will be included in the Reference Committee section of the Delegate materials and sent to the Delegates and Alternate Delegates at least 30 days in advance of the meetings.

REFERENCE COMMITTEE REPORTS: Reference Committee Reports will be posted on the TDA website and

participation by candidates

electronically at least 30

for ADA elected offices, the

days prior to the Annual

Candidates Forum will not

Session. The supplements

be held.

to the House Documents,

DIVISIONAL CAUCUSES:

containing the agenda and subsequent reports, will be sent after the March 2022 TDA Board of Directors

emailed in PDF format to the members of the House

Divisional Caucuses

meeting. The minutes of the

of Delegates (reports may

(Northwest, Northeast,

TDA Board shall be posted

be downloaded from any

Southwest, Southeast)

on the members’ side of

location with Internet

will be facilitated entirely

the TDA website and made

access). Printed copies will

through electronic virtual

available to the general

not be provided.

means at 6:00 p.m. CDT as

TDA membership once the

follows:

minutes are approved by

FINANCIAL FORUM:

the TDA Board of Directors •

Monday, April 25, 2022

in accordance with Policy

Northeast Division

26-2018-H. Delegates and alternates will receive all

The TDA SecretaryTreasurer will facilitate

•

a 1-hour questions and

Tuesday, April 26, 2022

House Documents in PDF

Southeast Division

format. Printed copies of the House Documents will not

answer financial forum open to all members who are

•

Wednesday, April 27, 2022

be provided.

Southwest Division

present at 9:30 a.m. on Thursday, May 5, 2022 in the same meeting room as Reference Committee A & B

•

Thursday, April 28, 2022

Wireless internet

Northwest Division

access will not be provided in the House

(Lost Pines 1).

Registration is required

of Delegates meeting

CANDIDATES FORUM:

and open to all current

room—please download

The ADA and TDA

additional information.

Candidates Forums will be held in Lost Pines 1 and 2 of the hotel on Friday, May

members—please see the

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or device prior to attendance (charging stations will be centrally located in the meeting rooms).

6, 2022, from 10:30 a.m. to 12:00 p.m. In the event

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115

ORAL

and maxillofacial pathology

Clinical History

A 15-year-old male presented to his dentist with pain involving the left mandible of unknown duration in the region of tooth #17. The patient otherwise appeared to be in good health, without any significant underlying medical conditions. Intraoral examination revealed no associated lesion and the associated tooth was vital. Radiographic examination showed an ill-defined radiolucency associated with the apical area of tooth #17 (Figure 1).

case of the month AUTHORS Kalu U.E. Ogbureke, BDS, MSc, DMSc, JD, FDSRCPS, FDSRCSEdin, FRCPath Professor, Department of Diagnostic and Biomedical Sciences, The University of Texas School of Dentistry at Houston, Houston, Texas

Dr Ahmad Millwala Katy, Texas

Ezinne I. Ogbureke, BDS, DMD Associate Professor, Department of General Practice and Dental Public Health, The University of Texas School of Dentistry at Houston, Houston, Texas

Figure 1. Panoramic radiograph shows an ill-defined radiolucency (arrow) associated with tooth #17.

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Figure 2. Hematoxylin and eosin-stained histologic sections of the curetted lesion. (A; mag. X40) shows histiocytes interspersed with eosinophils (bright red) at low power. (B; mag x200) shows giant cells (arrow) present in LCH. (C; mag. x400) shows aggregates of eosinophils (within oval circle) and interspersed with numerous lobulated (coffee bean-shaped) histiocytes, Langerhans cells.

of mononuclear histiocytic The following clinical decalcification and routine cells with irregular differential diagnoses tissue processing. lobulated nuclei admixed were considered: with small lymphocytes, developmental odontogenic Microscopic examination occasional plasma cells, lesions, including of hematoxylin and eosin giant cells, and clusters of odontogenic keratocyst stained sections from degranulating eosinophils and odontogenic tumors, the specimen revealed (Figure 2).The mononuclear such as amelobastoma. multiple soft tissue histiocytes were positive Malignancies, including a fragments of granulation for CD1a, S100, CD207 metastatic lesion was also tissue interspersed with (langerin), and CD163 considered in the clinical occasional dense fibrous (Figure 3; CD1a and S100 differential diagnosis. connective tissue and not shown).

Curettage of the lesion was numerous hemorrhagic performed, and the entire foci. The granulation What is your diagnosis? specimen was submitted tissue was remarkable for histopathologic for the presence of an See page 143 for the answer examination. The gross intense inflammatory cell and discussion. appearance of curetted infiltrate chiefly composed specimen revealed multiple tan and hemorrhagic fragments measuring approximately 1.1 x 0.9 x 0.6 cm in aggregate.

The entire specimen was Figure 3. Immunohistochemistry stains show diffuse immunopositivity for CD163 (A; mag. x200), and (B; mag. X200) CD207 (langerin) in Langerhans cells. submitted for short www.tda.org | March 2022

117

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119 11/30/20 2:48 PM

C. difficile: An Update f

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for Dentistry Abstract C. difficile infection (CDI) is a potential complication of antibiotic therapy, and while frequently associated with regimens of clindamycin, it is known to occur with any antibiotic. As such, practitioners should be aware of the signs and symptoms of CDI and the potential severity of the disorder, which may lead to death if not promptly and effectively managed. The purpose of this review article is refamiliarize dentists with the basic microbiology of C. difficile and its toxicity, and to review the diagnosis and clinical management of the disease based on current scientific literature, including relevant information on probiotics and their relationship to antibiotic-associated diarrhea and CDI.

Keywords C. difficile, antibiotic-associated diarrhea, probiotics, fidaxomicin, vancomycin

Disclaimer The information contained in this article is not intended as advice for the care and management of specific patients.

The opinions expressed here are those of the authors, and are not necessarily those of the University of Texas School of Dentistry at Houston or the Texas Dental Association.

Authors Hillary Bui, BS Second-year dental student, University of Texas School of Dentistry at Houston, Houston, Texas

Sydney Pham, BSA Second-year dental student, University of Texas School of Dentistry at Houston, Houston, Texas

Andrew Roberts, BBA Second-year dental student, University of Texas School of Dentistry at Houston, Houston, Texas

Mason Tobola, BS Second-year dental student, University of Texas School of Dentistry at Houston, Houston, Texas

Jayme Witek, BS Second-year dental student, University of Texas School of Dentistry at Houston, Houston, Texas

Arthur Jeske, PhD, DMD Professor, Department of General Practice & Dental Public Health and Associate Dean for Strategic Planning and Continuing Dental Education, University of Texas School of Dentistry at Houston, Houston, Texas Conflict of interest: The authors declare no conflict of interest regarding the products mentioned in the manuscript.

Address correspondence to: Dr Arthur Jeske, University of Texas School of Dentistry 7500 Cambridge St, Ste 6350, Houston, Texas 77054; Arthur.H.Jeske@uth.tmc.edu; 713-486-4506

www.tda.org | March 2022

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Introduction C. difficile suprainfection continues to represent a serious and potentially lifethreatening complication associated with the prescription of antibiotics in both the inpatient and outpatient settings, despite the introduction of newer agents and therapeutic regimens to treat it.

Dentists should be aware that while some antibiotics appear to be more likely to be associated with clinically-significant C. difficile complications (e.g., clindamycin), virtually any antibiotic can create conditions favorable to this disease, including amoxicillin.1

Dentists should be aware that while some

antibiotics appear to be more likely to be associated with clinically-significant C. difficile complications (e.g., clindamycin),

virtually any antibiotic can create conditions favorable to this disease

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Once these complications pass the stage of antibiotic-associated diarrhea, medical management becomes mandatory to prevent further development and eventual progression to pseudomembranous colitis.

The purpose of this article is to provide a review of recent publications related to C. difficile infection (CDI) and its diagnosis and management in order to update dental practitioners on this important topic.

RECLASSIFICATION OF CLOSTRIDIUM DIFFICILE TO CLOSTRIDIOIDES DIFFICILE In 2016, Lawson et al., based on moleculargenetic typing (16S rRNA gene sequence analyses), proposed that the organism then classified as Clostridium difficile was most closely related to Clostridium mangenotii, genetically and physiologically.2 According to an earlier publication by this group (2015)3, the genus Clostridium should be restricted to certain organisms genetically closely related to the type species (Clostridium butyricum), and organisms that fell outside of this organism’s RNA Cluster (I) should be reclassified, which included the former Clostridium difficile.

And while Clostridium difficile would otherwise have been renamed to its appropriate cluster (Cluster XI), in the genus Peptostreptococcaceae, such a new designation would likely be very disruptive, necessitating changes in a large number of publications, informational websites, medical insurance codes,

and pharmaceutical labels, among others.

Therefore, Lawson et al. proposed a new name, which would retain the same abbreviation for the genus (C) and retain the original species, allowing preservation of the universally-used and universally-understood name, “C. difficile”, and Clostridioides difficile became the type species of this new genus.2 Conveniently, abbreviations like “C diff”, “CDAD” and “CDI” can continue to be used.

RELEVANT FEATURES OF THE ORGANISM Clostrioides difficile is a gram-positive, anaerobic, spore-forming bacillus found in the gastrointestinal tract of humans, animals and in the environment. C. difficile is a member of the normal gut microflora, but its growth is suppressed by more dominant anaerobes.

Nevertheless, even minor disruptions of the gut (e.g., during antibiotic therapy) can lead to an imbalance of the microflora and create adverse effects on the host, in a process known as dysbiosis. Its spores are resistant to heat, acid, and antibiotics,

and spore germination is stimulated by bile acids, which partially explains the organism’s rapid growth within the gastrointestinal tract4 under conditions in which it gains a competitive environmental advantage.

It is transmitted by fecaloral route, and is a common cause of nosocomial infections associated with poor hand hygiene of hospital personnel. C. difficile produces 3 protein toxins, including C. difficile transferase toxin (CDT), C. difficile toxin A (TcdA), and toxin B (TcdB)5. The latter two are the main virulence factors—toxin A facilitates transport of toxins A and B intracellularly, and toxin B causes inflammation in the colon.6,7 These toxins result in damage to the epithelial cell cytoskeleton and ultimately result in breakdown of the gut mucosal barrier. The pathophysiologic outcome of this is severe loss of fluid and electrolytes from the lower GI tract.

CLINICAL FEATURES OF CDI4 Symptoms of C. diff. infection include severe diarrhea and lifethreatening colitis that may www.tda.org | March 2022

123

Symptoms of C. diff. infection include severe

diarrhea and lifethreatening colitis that may result in death, and the severity of the disease can range from mild diarrhea to

toxic megacolon.

124

result in death, and the severity of the disease can range from mild diarrhea to toxic megacolon. Most cases are preceded by antibiotic-associated diarrhea, which can be related to any antibiotic commonly used in dental practice.

There is no single test that can stand alone to confirm if patients have CDI, and it is important to differentiate the symptoms from other forms of diarrhea. Common types of diarrhea and their characteristics are: Diarrhea8 • Having 3 or more loose or watery stools/day due to reduced water absorption or increased water secretion—acute (lasting < 2 weeks) or chronic (lasting > 4 weeks) Travelers’ Diarrhea9 • Definition: 3 or more loose stools/day in addition to at least one other symptom (abdominal cramps, nausea, vomiting, tenesmus, fecal urgency, fever or dysentery) • Frequent problem with travelers from high-income

Texas Dental Journal | Vol 139 | No. 3

•

•

areas to lower- and middle-income areas Incidence rates remain high in Central America, risks increase with warmer temperatures Disease is usually selflimited (many cases spontaneously cured within 48 hours)

Lactose Intolerance10 • Definition: reduced lactase activity in the small bowel cellular brush borders • Lactase deficiency leads to lactose malabsorption and lactose is instead fermented • Symptoms: vomiting, diarrhea, flatulence (accumulation of gas), and abdominal pain Celiac Disease11 • Definition:chronic small intestinal inflammation due to gluten intolerance • Can lead to mucosal inflammation and villous atrophy, resulting in malabsorption • Symptoms: diarrhea, steatorrhea (abnormal quantities of fat in feces), loss of weight Irritable Bowel Syndrome (IBS)12 • Categorized as diarrhea-predominant, constipation-

•

•

predominant, or mixed Symptoms: abdominal pain, bloating, diarrhea, constipation—can overlap with Celiac disease Additional features include reduced quality of life, anxiety and depression

Inflammatory Bowel Disease (IBD)13 • Definition: chronic inflammation of gastrointestinal tract due to inappropriate inflammatory responses to intestinal microbes • Crohn’s disease (involves any part of GI tract) and ulcerative colitis (involves rectum and colon) • Symptoms: abdominal pain, diarrhea, rectal bleeding, fever, weight loss Clostridium difficile Infection (CDI)14 • C. difficile lives harmlessly in the colon, but can replace normal gut flora when individuals take antibiotics • Symptoms: diarrhea, fever, pain, abdominal tenderness progressing to colitis, death

LABORATORY TESTS FOR C. DIFFICILE Diagnosis is based on detection of C. difficile toxins in the feces.4 Falsenegative results occur frequently due to improper storage and transportation of samples (which may allow the specimen to become warmed). These tests include: • Cytotoxicity Assay15 o Tests effects of toxins on a cell culture after incubation o Limited use due to lack of lab standardization, long turn-around time • Nucleic Acid Amplification Test (NAAT)7 o PCR—test for gene that produces toxin B o High cost, very sensitive • Enzyme Immunoassay (EIA)7,15 o Test for glutamate dehydrogenase (GDH) • Metabolic enzyme expressed by all C. difficile strains o Test for toxins A and B • Less sensitive, low cost, easy to use, rapid turnaround time (1-2 hours) www.tda.org | March 2022

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In its early phase (antibiotic-

discontinuation of the

No single test should be used as a stand-alone test to diagnose CDI. Therefore, a 2-step algorithm is used to improved diagnostic reliability. This includes 1) GDH EIA or NAAT for a high negative predictive value (to rule out infection), and 2) testing for toxins A/B EIA (for a high positive predictive value).

offending antibiotic may

TREATMENTS FOR C. DIFFICILE INFECTION

associated diarrhea),

be sufficient to restore gut flora and gut health.

126

It is imperative that antibiotic therapy be discontinued with the appearance of diarrhea, regardless of the type of antibiotic that was prescribed. Patients should be made aware of the serious implications of diarrhea and this should be noted on the prescription (in the Signa section). It is also imperative that no over-the-counter or prescription antidiarrheal drugs be prescribed (e.g., Kaopectate®, loperamide). In its early stages, diarrhea helps rid the GI tract of C. difficile toxins and is actually a protective mechanism for the patient.

Texas Dental Journal | Vol 139 | No. 3

o

o

Recommended treatments are based on the severity of the disease. In its early phase (antibiotic-associated diarrhea), discontinuation of the offending antibiotic may be sufficient to restore gut flora and gut health.

For more advanced forms (colitis), antimicrobial therapy continues to be considered as the treatment of first choice.16 Published antibiotic regimens for the management of CDI include7: o Metronidazole (500 mg intravenously 3 times a day for 10–14 days);

Vancomycin (125 mg orally 4 times a day for 10–14 days) (dose may be increased to 500mg per day if patients do not respond between 24-48 hours); If patients cannot tolerate vancomycin, fidaxomicin (Dificid®) may be considered with a 200-mg dose, twice daily.

Dentists may not be familiar with fidaxomicin, which was approved by the FDA in 2011 and is now regarded as the drug of choice for CDI, primarily because its use is limited to the management of this disorder. It is a macrolide, but cannot be used interchangeably with other macrolides (e.g., azithromycin) because it is designed to act locally within the G.I. tract, having very low systemic absorption. It is available in both liquid and solid dose forms and is contraindicated only in cases of fidaxomicin allergy. The most common adverse effects are nausea, vomiting, abdominal pain, gastrointestinal bleeding, anemia and neutropenia.

In pediatric patients, fever and constipation may also be observed.

If patients do not achieve improvement in their treatment, a promising alternate therapy would be suggested, known as fecal microbiota transplantation.4,17 Discussion of this treatment option, however, is outside the scope of this article.

Recurrent CDI is not infrequent, even after successful antibiotic therapy of the initial infection.18 Risk factors for recurrence include advanced age, use of an antibiotic, gastric acid suppression, infection with a hypervirulent strain, and renal insufficiency.

PROBIOTICS AND CDI Many dentists and dental patients consider coingestion of probiotics with antibiotics to be a safe and effective preventive measure to avoid antibioticassociated diarrhea and even CDI. While controversial, this approach is supported by some evidence, particularly when specific types of probiotic formulations are utilized in well-designed, randomized clinical trials.19, www.tda.org | March 2022

127

However, these formulations are not without risk, including possible Lactobacillus bacteremia in medically compromised patients.20 A recent systematic review found that probiotics are effective in preventing antibioticassociated diarrhea, and “may also be a beneficial strategy for CDIs, but randomized controlled trials are scarce.19” Significantly, none of the probiotic studies included in the review significantly improved secondary prevention of CDI. 20, 21

SUMMARY AND CONCLUSIONS C. difficile infection remains a significant and potentially life-threatening illness in patients taking antibiotics, and can become extremely serious when patients and/ or their healthcare providers ignore the initial symptoms (e.g., diarrhea) or attempt palliative treatment with over-the-counter and prescription anti-diarrheal agents or probiotics. Dentists should warn patients about the implications of diarrhea whenever an antibiotic is prescribed, regardless of the antibiotic class or the use of a probiotic. Failure to discontinue the antibiotic and appropriately refer the patient for medical evaluation and treatment when serious signs and symptoms occur can have lethal consequences. In the event that the dentist encounters a patient with signs and symptoms of C. diff. infection possibly related to another practitioner’s antibiotic prescription, the dentist should inform the patient of their current health condition without passing judgement on the prescribing dentist, who may not be aware of the patient’s condition.22 Furthermore, once informed about their patient’s condition, the prescribing dentist should involve himself/herself as appropriate, which may involve providing information about the prescription, the need for the prescription, etc., and only to entities authorized to receive the information under the provisions of HIPAA. REFERENCES 1.

2.

3.

4.

5.

Beacher N, Sweeney MP, Bagg J. Dentists, antibiotics and Clostridium difficileassociated disease. Brit. Dent. J. 2015;219(6):275-279.

Lawson PA, Rainey FA, Tyrrell KL, Finegold SM. Reclassification of Clostridium difficile as Clostridioides difficile (Hall and O’Toole 1935 Prevot 1938). Anaerobe 2016;40:9599.

Lawson PA, Rainey FA. Proposal to restrict the genus Clostridium (Prazmowski) to Clostridium butyricum and related species. Int. J. Syst. Evol. Microbiol. 2015;66:10091016.

Czepiel J. et al. Clostridium difficile infection: review. Eur. J. Clin. Microbiol. Infect. Dis. 2019;38(7):1211-1221.

Aktories K, Schwan C, Jank T. Clostridium difficile toxin biology. Ann. Rev. Microbiol.

2017;71:281-307.

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Mada PK, Alam MU. Clostridium difficile. StatPearls (internet), Jan. 2021. https://pubmed.ncbi.nlm.nih. gov/28613708/ Kelly CR et al. ACG Clinical Guidelines: Prevention Diagnosis and Treatment of Clostridioides difficile Infections. Am. J. Gastroenterol 2021;116(6):1124-1147.

Nemeth V, Pfleghaar N. Diarrhea.

StatPearls (internet), Jan. 2021. https://pubmed.ncbi.nlm.nih. gov/28846339/ Steffen R. Epidemiology of traveler’s diarrhea. J. Travel Med. 2017;24(Suppl. 1):S2-S5.

Leis R et al. Effects of prebiotic and probiotic supplementation on lactase deficiency and lactose intolerance: A systematic review of controlled trials.

Nutrients 2020;12(5):1487.

El-Metwally A et al. The epidemiology of celiac disease in the general population and high-risk groups in Arab countries: A systematic review.

Biomed. Res. Intl. 2020;1-13,12.

Usai-Satta P et al. Irritable bowel syndrome and glutenrelated disorders. Nutrients 2020;12(4):1117-1124.

Selveratnam S et al. Epidemiology of inflammatory bowel disease in South America: A systematic review. World J. Gastroenterol. 2019;25(47):68666875.

Nelson RL, Suda KJ, Evans CT. Antibiotic treatment for Clostridium difficile-associated diarrhea in adults.

Cochrane Database Syst. Rev. 2017;3(3):CD004610.

Gateau C, Couturier J, Coia J, Barbut F. How to diagnose infection caused by Clostridium difficile. Clin.

Microbiol. Infect. 2018;24(5):463468.

Peng Z et al. Advances in the diagnosis and treatment of Clostridium difficile infections.

Emerging. Microbes Infection.

2018;7(1):15-29.

Imdad A. et al. Fecal microbiota transplantation for the treatment of recurrent Clostridioides difficile.

Cochrane Database Syst. Rev. 2021, Issue 2:CD013871.

Song JH, Kim YS. Recurrent Clostridium difficile infection. Risk factors, treatment and prevention.

Gut and Liver 2019;13(1):16-24.

McFarland LV. Probiotics for the primary and secondary prevention of C. difficile. Infections: A metaanalysis and systematic review.

Antibiotics 2015;4(2):160-178.

Goldstein EJC, Johnson SJ, Maziade P-J, Evans CT, Sniffen JC, Millette M, McFarland LV. Probiotics and the prevention of C. difficile infection.

Anaerobe 2017;45:114-119.

McFarland LV, Ship N, Auclair J, Millette M. Primary prevention of Clostridium difficile infections with a specific probiotic combining Lactobacillus acidophilus, L. casei, and L. rhamnosus strains: assessing the evidence. J. Hosp. Infect.

2018;99(4):443-452.

ADA Principles of Ethics and Code of Professional Conduct, American Dental Association, 2020, Chicago, IL.

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Covid, A Hybrid Meeting, and a Dues Increase

U

sually with this annual article we highlight the end-of-year differences between our budget versus our actuals. This year our auditors were delayed due to unforeseen issues so there are no official audited numbers to discuss with the members prior to the TDA House of Delegates meeting in May. Yet we will discuss some of the “unofficial” numbers from 2021 to explain why the TDA will have a small loss for the year, plus detail why there will be a request for a $20 dues increase in 2023.

To reflect on 2021, the TDA, along with just about every other business, experienced several obstacles that have impacted our financial outcome. Our biggest two revenue sources, membership dues (7a) and annual session (1 and 8), both took negative hits in 2021. TDA also ramped up in-person meetings and this caused travel expenses to increase compared to nearly a full year of Zoom meetings in 2020.

The annual session meeting was one of the very first dental meetings in the country to return to an in-person meeting. TDA was also the second meeting to be hosted at San Antonio’s Henry B. Gonzalez Convention Center in 2021. Even though the TDA did not produce as much revenue as was budgeted (budget = $348,351, actual = $35,400), it still gave our membership the expected valued continuing education. Dr. Hutto and the Council on Annual Meeting and Continuing Education Programs (CAMCEP) persevered through many hurdles (Covid restrictions, hotel issues, IT upgrades to offer virtual access, speaker requirements, etc…), all to create an environment for quality education. It was not a normal year and they deserve significant praise for being able to get a meeting together, much less a hybrid meeting. So, Thank You Red Coats for helping to meet our CE needs.

As for membership, TDA ended 2021 with 8,857 members, with 7,335 of them being active licensed dentists. We continue down the road to recovery from a drop in membership and the corresponding dues revenue (line 7a) due to COVID and other factors. The actual dues revenue received in 2021 was $2,468,330 versus

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Texas Dental Journal | Vol 139 | No. 3

Dr Cody Graves

Secretary-Treasurer, TDA •

That’s a real old picture up there. I look young!

•

The proposed 2023 budget is $5,769,988.

•

Dues are suggested to increase for the first time since 2015 by $20.

•

The budget is balanced in accordance with TDA Bylaws without using methods of finance outside of expected revenues.

•

The riders, allowing limited revisions to the budget, are included in this budget. The TDA Smiles Foundation has been eliminated this year due to financial constraints.

•

The 2023 budget is a basic operational budget. Any strategic plan, membership initiatives, or additional meetings not currently funded will need to be funded from our reserves, subject to Board approval.

a budget of $2,598,712 (a shortfall of -$130,382 and once again not audited numbers).

Wrapping up 2021 does not consist of all bad news. TDA received forgiveness on a PPP loan to cover personnel salary of $255,100 and our expenses (under 80% of budget) were well controlled. Also, the financial markets allowed our long-term investments, (life to date) as of 12/31/2021, to increase close to a million dollars of unrealized gain.

Ultimately, once the audit is completed, we can determine the exact numbers, but the TDA is estimated to lose about -$100,000 to -$130,000 in 2021.

That brings us to the 2023 budget. I’ll treat you readers like I do the board. Start on the back page of the budget, which is the Building (6 and 13). TDA has the entire first floor vacant and one suite on the second but the remainder of the building is leased out. We are forecasting (if everything stays the same) a small surplus revenue from our building in 2023.

Next page up is Communications (3-5, 10-12), which is Dr Dan Jones’ arena.

An item to note on this page is the breakdown of TDA’s three outsourced consultants in each of the area’s expenses (10a, 11a, 12a). The addition of Sales Commissions (10e, 11d, 12b) from TDA’s soonto-be new outsourced sales

and marketing company (MCI Sales). Advertising continues to be the biggest driver of revenue and $17 dollars from every dues paying member goes to the Texas Dental Journal, plus $5 goes to the TDA Today.

Pages 4 and 5 are the Annual Session and Continuing Education (1, 2, 8, 9) sections.

The budget estimates about a 15% reduction from 2019 actuals for clinics for continuing education (1b) and registration (1g) revenue.

Expenses assume increases in audio-visual costs (8a).

The consultants line item (8h) includes outsourced Strategic Association Management’s services and MCI Sales.

The CE programs consist of revenues and expense estimated for the dental concierge app subscriptions, 18 online courses, 2 regional meetings, and a dentist-only conference. These items are only estimated due to no historic trends.

Getting closer to the front page, page 3 is the BOD, Councils, Committees, ADA, HOD, and other Expenses (17-22). With such a jump in expenses this year to try and kick start our membership growth, most of these line items have been reduced to help control expenses. Next year will be a legislative year for Texas (beginning January 10, 2023), the ADA will be in Orlando, and we should begin to have regular Texas HOD meetings.

Page 2 is Central Office Departments (16) in which a new meetings director employee is scheduled to be added. Health insurance (16d) took a big 12% increase in 2022 and we estimate another 8% increase in 2023. All Other Expenses (aa-gg) have been reduced.

Finally, to the first page.

Most of these line items have been covered except for MBL partnership revenue (7f) which is budgeted to stay the same. Expenses were reduced for Capital Improvements (14), Non-budget Contingency (15) and the TDA Smiles Foundation (23) due to budget constraints.

With these adjustments to both expense increases and revenue decreases, the TDA Board of Directors is recommending a $20 dues increase. Once again, TDA’s dues have been constant for 7 years, so please allow a small increase to cover expenses to keep providing our membership value.

Once again, I want to thank the Budget, Assets, and Finance Committee for recommending a budget that remains operational, yet efficient, and the TDA Board of Directors for approving this budget for the TDA House of Delegates to discuss. It is my honor to serve as the Texas Dental Association’s Secretary/Treasurer. Please feel free to ask any question.

If I can answer it, I will. If I do not know the answer, I’ll find it. www.tda.org | March 2022

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2023 Proposed Budget Texas Dental Association

PLEASE NOTE: For individual line-item explanations, please visit tinyurl.com/budget-explanation

2021 Budget

Revenues ANNUAL SESSION

PUBLICATIONS/ WEBSITE

1.

Annual Session

2.

Continuing Education Programs 43,000

3.

Journal 333,444 4.

TDA Today 43,115 5.

TDA Website 37,000 Total Publications/Website

BUILDING OPERATIONS

PUBLICATIONS/ WEBSITE

413,559

583,910

2023 Proposed 1,329,968

150,000

664,699

326,151 40,970 37,000

358,806 38,384 45,000

404,121

442,191

6.

Building 351,531 313,562 304,713

7.

Operating a. Dues 2,598,712 2,549,468 2,571,971 b. Investment Earnings-Sweep 50,000 40,000 10,000 c. Miscellaneous 35,000 168,640 75,000 d. Affiliates Administration 92,740 96,908 96,446 e. MBL Partnership 290,000 275,000 275,000

Total Operating 3,066,452 3,130,016 3,028,417 TOTAL REVENUES

Expenses

ANNUAL SESSION

1,418,383

2022 Budget

5,292,925

4,581,609

5,769,988

8.

Annual Session 1,070,032 76,083 1,043,700

9.

Continuing Education Programs 5,500 30,000 354,110

10. Journal 230,050 230,050 305,220 11. TDA Today 110,500 110,500 98,750 12. TDA Website 44,800 55,800 53,750 Total Publications/Website

385,350

396,350

457,720 295,235

BUILDING

13.

Building

315,603

325,141

CAPITAL IMPROVEMENTS

14.

Capital Improvements

10,000

10,000

0

CONTINGENCY

15.

Non Budgeted Contingency

19,000

29,000

5,000

CENTRAL OFFICE

16.

Central Office Departments

2,701,911

2,866,450

BOARD OF DIRECTORS

17.

COMMITTEES COUNCILS ADA/NATIONAL ORGANIZATIONS

2,971,172

Board of Directors 205,985 204,665

18. Committees 21,045 21,220

19. Councils 203,594 164,895

181,895

20.

18,070 164,230

ADA /National Organizations

186,205

165,815

135,180

65,700

45,350

80,675

OTHER EXPENSE

21. House of Delegates

22. Other expense

53,000

196,640

38,000

CONTRIBUTIONS

23.

TDA Smiles Foundation

50,000

50,000

25,000

TOTAL EXPENSES

5,292,925

4,581,609

5,769,988

REVENUE OVER EXPENSE

0

0

0

HOUSE OF DELEGATES

24.

25.

Method of Finance Adjustment TDA Financial Services, Inc. Cash Dividend ADJUSTED REVENUE OVER EXPENSE

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Texas Dental Journal | Vol 139 | No. 3

0

0

0

Central Office Departments

2023 Proposed Budget Texas Dental Association 2021 Budget

2022 Budget

2023 Proposed

16. Central Office Departments PERSONNEL

Personnel: a. Regular Salaries 1,536,820 1,655,619 1,753,146 b. Payroll Taxes 117,567 125,395 133,662 c. Health Insurance 167,567 173,634 206,053 d. Retirement 134,079 157,868 163,400 Total Personnel

OFFICE OPERATIONS

SERVICES

OTHER EXPENSES

1,956,033

2,112,516

2,256,261

Office Operations: e. Insurance—Directors/Officers 50,477 59,733 57,681 f. Leases—Equipment 39,651 42,447 34,526 g. Maintenance 14,038 15,800 16,550 h. Postage and Couriers 22,802 10,975 7,975 i. Printing 16,200 12,300 12,300 j. Supplies—Office 14,150 13,112 8,112 k. Taxes—State and Local 4,039 3,539 4,500 l. Information Technology 13,500 10,728 10,672

Total Office Operations 174,857 168,634 152,316

Services: m. Accounting Services—Payroll 4,800 4,800 4,800 n. Accounting and Auditing Services 32,412 35,000 36,450 o. Bank Charges 17,500 19,000 19,000 p. Consultants 30,396 31,200 31,200 q. Legal Services 154,000 159,000 159,000 r. Lobbying 201,500 190,500 201,500 s. Gifts and Memorials 1,000 1,950 1,450

Total Services 441,608 441,450 453,400

Other Expenses: t. Dues Processing 85,000 100,000 75,000 u. Education and Organizational Development 11,250 10,000 7,500 v. Meetings 2,600 4,000 2,000 w. Professional Dues & Memberships 3,150 3,430 2,800 x. Subscriptions 2,949 6,800 5,850 y. Recruiting 1,000 1,000 500 z. Travel 23,465 18,620 15,545

Total Other Expenses 129,414 143,850 109,195

Total Central Office 2,701,911 2,866,450 2,971,172

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Board of Directors, Councils, Committees, ADA, HOD BOARD OF DIRECTORS

COMMITTEES

COUNCILS

2023 Proposed Budget Texas Dental Association 2021 Budget

Total Board of Directors 205,985 204,665 181,895

18. Committees: a. Audit 1,540 1,615 0 b. Awards 17,095 17,095 17,220 c. Budget, Assets and Finance 0 0 0 d. Community Fluoride 1,300 1,300 600 e. Strategic Affairs 1,110 1,210 250 Total Committees 21,045 21,220 18,070

19. Councils: a. Annual Meeting and CE Programs 10,350 10,850 7,970 b. Legislative and Regulatory Affairs 100,699 58,560 87,995 c. DENPAC 38,575 40,345 32,425 d. Dental Licensing, Standards and Education 9,680 10,155 7,475 e. Ethics and Judicial Affairs 2,080 2,180 1,980 f. Governance 7,660 7,910 2,760 g. Membership, New Dentists and Students 19,000 18,695 16,525 h. Peer Review 2,550 2,600 1,500 i. Professions and Trends 5,000 5,250 3,340 j. Public Health and Access to Care 8,000 8,350 2,260 k.

TOHPAC 0 0 0

164,230

186,205

165,815

135,180

65,700

45,350

80,675

22. Other Expense a. Federal Income Tax 35,000 35,000 30,000 b. TDA Advocacy Academy 0 0 0 c. TDA Conferences 10,000 10,000 0 d. Alliance/TDAA Stipends 8,000 8,000 8,000 e. Building Loan Interest 0 143,640 0 Total Other Expense

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164,895

21. House of Delegates: a. HOD 50 Year and Life Luncheon 5,700 7,700 7,700 b. HOD Headquarters 58,000 35,650 70,975 c. HOD Past President’s Breakfast 2,000 2,000 2,000 Total House of Delegates

OTHER EXPENSE

203,594

20. ADA /National Organizations: a. ADA Delegates 150,405 120,015 135,180 b. ADA 15th Trustee Headquarters 0 10,000 0 c. ADA Texas Reception 35,800 35,800 0 Total ADA /National

HOUSE OF DELEGATES

2023 Proposed

17. Board of Directors: a. President 27,000 28,705 20,985 b. Presiden­—Stipend 36,000 36,000 32,400 c. President Elect 8,830 8,520 7,070 d. President Elect—Stipend 8,400 8,400 7,200 e. Past President 5,400 5,230 4,830 f. Secretary Treasurer 5,400 5,230 4,830 g. Secretary Treasurer—Stipend 8,400 8,400 7,200 h. Editor 4,000 3,830 3,430 i. Editor—Stipend 8,400 8,400 7,200 j. Vice Presidents 21,860 21,280 19,480 k. Senior Directors 21,860 21,280 19,480 l. Directors 21,860 21,280 19,480 m. Other Officers 9,050 8,460 7,910 n. Board Meetings 19,525 19,650 20,400

Total Councils ADA/NATIONAL ORGANIZATIONS

2022 Budget

Texas Dental Journal | Vol 139 | No. 3

53,000

196,640

38,000

2023 Proposed Budget Texas Dental Association Annual Session

2021 Budget

2022 Budget

2023 Proposed

ANNUAL SESSION REVENUE

Annual Session Revenue a. Advertising 4,000 0 8,000 b. Clinics for Continuing Education 812,383 0 690,525 c. Exhibits 415,000 0 450,000 d. Miscellaneous 0 583,910 0 e. Other Groups 17,000 0 17,000 f. Registration 95,000 0 74,443 g. Sponsorships 75,000 0 90,000

Total Annual Session Revenue 1,418,383 583,910 1,329,968

ANNUAL SESSION EXPENSE

8.

1.

Annual Session Expense a. Audio—Visual 164,337 0 150,000 b. Bank Charges 30,000 0 25,000 c. Clinician Honorariums 200,000 0 150,000 d. Clinician Support 100,000 0 90,000 e. Consultants 100,000 50,000 228,250 f. Exhibits 160,000 0 150,000 g. Hospitality Suite 20,000 0 15,000 h. Insurance 4,000 0 10,425 i. Miscellaneous 1,750 0 1,750 j. Onsite Program 6,000 0 0 k. Other Groups 16,000 0 16,000 l. Postage 6,000 0 6,000 m. President’s Reception 0 0 0 n. Promotion 30,000 0 20,000 o. Registration 137,000 0 125,000 p. Shuttle Services 10,000 0 10,000 q. Stipends 15,000 15,000 15,000 r. Supplies 200 0 200 s. Information Technology 0 0 0 t. TDA Party 30,000 0 0 u. Travel 24,745 11,083 31,075 v. VIP Reception 15,000 0 0

Total Annual Session Expense 1,070,032 76,083 1,043,700

Annual Session Net Revenue (Loss) 348,351 507,827 286,268

www.tda.org | March 2022

139

2023 Proposed Budget Texas Dental Association

Continuing Education REVENUE

2021 Budget

2022 Budget

2023 Proposed

2.

Continuing Education Revenue a. Advertising 0 0 6,000 b. Clinics for Continuing Education 43,000 150,000 213,738 c. Exhibits 0 0 11,500 d. Miscellaneous 0 0 9,335 e. Subscriptions 0 0 40,446 f. Registration 0 0 332,640 g. Sponsorships 0 0 51,040

Total Continuing Education Revenue 43,000 150,000 664,699

EXPENSE

140

9.

Continuing Education Expense a. Audio—Visual 0 0 30,000 b. Bank Charges 0 0 6,000 c. Clinician Honorariums 5,500 30,000 85,000 d. Clinician Support 0 0 12,000 e. Consultants 0 0 102,806 f. Exhibits 0 0 1,000 g. F&B 0 0 85,750 h. Insurance 0 0 0 i. Miscellaneous 0 0 900 j. Postage 0 0 100 k. Promotion 0 0 10,000 l. Registration 0 0 2,000 m. Stipends 0 0 0 n. Supplies 0 0 1,000 o. Travel 0 0 5,350 p. Information Technology 0 0 12,204

Total Continuing Education Expense 5,500 30,000 354,110

Continuing Education Net Revenue (Loss) 37,500 120,000 310,589

Texas Dental Journal | Vol 139 | No. 3

2023 Proposed Budget Texas Dental Association Publications/ Website

2021 Budget

JOURNAL REVENUE

3.

TDA TODAY REVENUE

4.

2022 Budget

2023 Proposed

TDA Journal Revenue a. Advertising 222,248 222,248 265,600 b. Single Issue Purchases 255 255 100 c. Subscriptions 110,941 103,648 93,106 d. Miscellaneous 0 0 0

Total TDA Journal Revenue 333,444 326,151 358,806

JOURNAL EXPENSE 10. TDA Journal Expense a. Consultants 49,500 49,500 49,500 b. Meetings 200 200 200 c. Postage and Couriers 50,000 50,000 45,000 d. Printing and Production 129,950 129,950 140,500 e. Sales Commissions 0 0 69,720 f. Supplies 200 200 100 g. Travel 200 200 200

Total TDA Journal Expense 230,050 230,050 305,220

TDA Today Revenue a. Advertising 11,000 11,000 11,000 b. Subscriptions—Membership Dues 32,115 29,970 27,384

Total TDA Today Revenue 43,115 40,970 38,384

TDA TODAY EXPENSE 11. TDA Today Expense a. Consultants 49,500 49,500 35,000 b. Postage 31,000 31,000 31,000 c. Printing and Production 30,000 30,000 30,000 d. Sales Commissions 0 0 2,750

Total TDA Today Expense 110,500 110,500 98,750 WEBSITE REVENUE

WEBSITE EXPENSE

5.

TDA Website Revenue a. Advertising 37,000 37,000 45,000 b. TDA Affiliates Advertising 0 0 0

Total TDA Website Revenue 37,000 37,000 45,000 12. TDA Website Expense a. Consultants 39,000 50,000 42,000 b. Sales Commissions 0 0 11,250 c. Software and Software Support 300 300 0 d. Subscriptions—Publications 500 500 100 e. Website Hosting 5,000 5,000 400

Total TDA Website Expense 44,800 55,800 53,750

3-5. Total Publication/Web Revenues 413,559 404,121 442,191 10-12. Total Publication/Web Expense 385,350 396,350 457,720

Communications Net Revenue (Loss) 28,209 7,771 (15,529)

www.tda.org | March 2022

141

2023 Proposed Budget Texas Dental Association Buildings

2021 Budget

2022 Budget

2023 Proposed

BUILDING REVENUE

TDA Building Revenue a. Lease Income 351,531 313,562 304,713

Total TDA Building Revenue 351,531 313,562 304,713

BUILDING EXPENSE

13. TDA Building Expense a. Building Lease Broker Fees 9,000 9,000 0 b. Building Management Fees 22,703 23,000 28,000 c. Insurance—Operating 28,000 34,141 23,235 d. Repairs and Maintenance—Equipment 40,000 40,000 30,000 e. Service Contracts 85,000 85,000 90,000 f. Supplies 5,000 5,000 2,000 g. Taxes—State & Local 80,000 82,500 85,000 h. Utilities 45,900 46,500 37,000

Total TDA Building Expense 315,603 325,141 295,235

6.

BUILDING MAINTENANCE

Building Net Revenue (Loss)

35,928

(11,580)

9,478

RIDERS

1.

General Revision Authority. The Board of Directors is authorized to revise and amend the 2023 budget, in the aggregate or any single line item, during the time period August 1, 2022 and November 30, 2022, with such authority subject to the following: a. The Board must, upon review and recommendation by the Secretary-Treasurer, certify a new revenue estimate.

Such estimate shall be based on reasonable projections using know factors affecting dues and non-dues revenues. b. The originally budgeted expenditures for the House of Delegates shall not be reduced unless the Speaker recommends to the Board in writing or verbally as reflected in the minutes of the Board, that the originally budgeted expenditures be reduced. c. Overall expenses may not, in aggregate, be increased by an amount greater than 10% of the original amount. Any expected net gain net of 10% adjustment in expenses will be allocated to non-budgeted contingency items. d. The revised budget shall be published in the Texas Dental Journal and delivered electronically to the Speaker for distribution to the House of Delegates.

2.

Report of Expenditures and Methods of Finance. Any amounts expended pursuant to a duly adopted rider shall be reported in a manner that is consistent with reporting for other expenditures, and shall be clearly identified with the enabling rider and method of finance.

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Texas Dental Journal | Vol 139 | No. 3

ORAL

and maxillofacial pathology diagnosis and management—from page 117

Langerhans Cell Histiocytosis Discussion Langerhans cell histiocytosis (LCH) was previously known as “histiocytosis X”, because of a poor understanding of its etiology.1,2 It is now known to be a reticuloendothelial system disorder manifesting as a clonal disease of myeloid dendritic cells.3 Although LCH has been diagnosed in all age groups, the disease predominantly affects children in the age range of 1 to 4 years.3 The relative rarity of LCH increases the risk of underdiagnosis and misdiagnosis, and therefore underscores the need for a high index of suspicion for osteolytic bone lesions presenting with no apparent etiology.4 Historically, LCH was characterized by 3 clinical variants: Letterer-Siwe, affecting mainly infants, presents as an acute disseminated disease involving multiple organ systems; Hand-SchullerChristian disease, which

also may involve the skeletal and extraskeletal tissues; and eosinophilic granuloma, which presents as a chronic, localized form of LCH typically involving the skeleton, but occasionally also extraskeletal tissues in adults.4 A congenital and syndromic form of LCH, called Hashimoto– Pritzker syndrome, is also recognized, and patients present with deep subcutaneous skin lesions.4 A recent revision of the classification of histiocytosis by the Histiocyte Society, classifies LCH as “single system”-, “lung”- and “multisystem” based on site and organ (liver, spleen, bone marrow) dysfunction.4,5 In single system LCH, the skin is most commonly affected, followed by the lymph nodes and lungs.6 When the skeleton is affected, the skull, long bones, pelvis, ribs, vertebra, and posterior mandible are the most common sites.4,7

Clinical presentations of oral cavity LCH are hardly straight forward resulting in significant challenges when attempting to establish a differential diagnosis.

Common sites are the jaw bones as well as the gingiva and periodontium.

In these locations, the clinical features often mimic a constellation of more common entities related to periodontal diseases, such as gingival epulides, granulomatous or ulcerative lesions, or malignancies.8,9 Furthermore, early intraoral lesions confined to the maxillofacial skeleton are not always apparent during oral examination and are only discovered fortuitously on radiographs, where they present as radiolucent osteolytic processes.

Such instances generate additional considerations in the differential diagnosis, including odontogenic lesions, as in the present case, thereby necessitating a biopsy to determine the histopathologic diagnosis of the lesion. Radiographically, LCH of the jaw presents as www.tda.org | March 2022

143

ORAL

and maxillofacial pathology, continued

a punched out radiolucency with ill-defined borders, often accompanied by severe alveolar bone resorption leading to the typical tooth/teeth “floating in space” as in the present case.2

as a surrogate marker for Birbeck granules.8 These immunophenotypic

Figure 3. Immunohistochemistry stains show diffuse immunopositivity for CD163 (A; mag. x200), and (B; mag. X200) CD207 (langerin) in Langerhans cells.

The classic histopathologic features of LCH include the identification of numerous histiocytes exhibiting coffee bean-shaped (lobulated) nuclei and inconspicuous nucleoli with eosinophilic cytoplasm.10 These are interspersed with variable numbers of aggregated and degranulating eosinophils throughout the sections, in additions to neutrophils, plasma cells, lymphocytes, and sometimes, multinucleated giant cells.10 Diagnosis is usually confirmed with immunostains for CD1a, S100, CD207 (langerin), and CD163 positivity in the Langerhans cell population.11,12 Further evaluation by electron microscopy, demonstrates the presence of Birbeck granules, which are tennis racket shaped organelles, within the cytoplasm of the histiocytes. The recently discovered CD207 (langerin) serves

144

characteristics of LCH were confirmed in the present case (Figure 3).

Texas Dental Journal | Vol 139 | No. 3

The mainstay of treatment for localized oral LCH is surgery. In certain instances, surgery is augmented with steroid injections.4 In cases of recurrence, or extensive lesions, patients may be treated with radiotherapy, singly or in combination with surgery.4 However, in the case of extensive disease with organ dysfunction, or in classic systemic LCH, chemotherapy significantly improves outcome.4,5 Relatively new treatment includes the administration of monoclonal CD1a antibody in combination with any of the above traditional therapies.13 The prognosis of localized LCH is good. Overall prognosis however, is dependent on the age of patient, number of sites involved, whether or not disease is multisystemic, and whether or not disease has already resulted in organ/system dysfunction.

Prognosis is generally poor in patients younger than 2 years of age, those with multiple sites or multiorgan involvement, and those with organ dysfunction at the time of diagnosis.5

References 1.

2.

3.

4.

5.

6.

7.

Gorsky M, Silverman S Jr., Lozada F, Kushner J. 1983.

Histiocytosis X: Occurrence and oral involvement in six adolescent and adult patients. Oral Surg Oral Med Oral Pathol. 55(1):24-28.

Altay MA, Sindel A, Özalp Ö, Kocabalkan B, Özbudak İH, Erdem R, Salim O, Baur DA. 2017. Langerhans cell histiocytosis: A diagnostic challenge in the oral cavity.

Case Rep Pathol 2017:1–6.

Lian C, Lu Y, Shen S. Langerhans cell histiocytosis in adults: a case report and review of the literature.

2016. Oncotarget.

5;7(14):18678-18683.

Cherian LM, Sasikumar D, Sathyan P, Varghese BE. 2021. Langerhans cell histiocytosis: A diagnostic enigma in the oral cavity.

J Oral Maxillofac Pathol.

25(Suppl 1):S27-S31.

Rao DG, Trivedi MV, Havale R, Shrutha SP. 2017. A rare and unusual case report of Langerhans cell histiocytosis.

J Oral Maxillofac Pathol.

21:140–144.

Hicks J, Flaitz CM. 2005.

Langerhans cell histiocytosis: Current insights in a molecular age with emphasis on clinical oral and maxillofacial pathology practice. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontology. 100(2):S42– 66.

Bedran NR, Carlos R, de Andrade BAB, Bueno APS, Romañach MJ, Milito CB. 2018. Clinicopathological and Immunohistochemical study of head and neck langerhans cell histiocytosis from Latin

8.

9.

10.

11.

12.

13.

America. Head Neck Pathol.

12:431–439.

Morimoto A, Oh Y, Shioda Y, Kudo K, Imamura T. 2014. Recent advances in Langerhans cell histiocytosis.

Pediatr Int. 56(4):451-461.

Aricò M, Girschikofsky M, Généreau T, Klersy C, McClain K, Grois N, Emile JF, Lukina E, De Juli E, Danesino C. 2003. Langerhans cell histiocytosis in adults. Report from the International Registry of the Histiocyte Society. Eur J Cancer.

39(16):2341-2348.

Felstead AM, Main BG, Thomas SJ, Hughes CW. 2013. Recurrent Langerhans cell histiocytosis of the mandible. Br J Oral Maxillofac Surg. 51(3):264-265 Sahm F, Capper D, Preusser M, Meyer J, Stenzinger A, Lasitschka F, et al. 2012.

BRAFV600E mutant protein is expressed in cells of variable maturation in Langerhans cell histiocytosis. Blood.

120:e28–34.

Grana N. Langerhans cell histiocytosis. 2014. Cancer Control. 21:328–334.

Ramos-Gutierrez E, AlejoGonzalez F, Ruiz-Rodriguez S, Garrocho-Rangel J, PozosGuillen A. 2016. Langerhans cell histiocytosis: Current concepts in dentistry and case report. J Clin Exp Dent.

8:e102–108.

www.tda.org | March 2022

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VALUE

for your

Provided by:

profession

EMAIL CYBERSECURITY IS CRITICAL FOR YOUR PRACTICE KNOW HOW TO PROTECT YOUR OFFICE

By Robert McDermott; President and CEO, iCoreConnect

146

Texas Dental Journal | Vol 139 | No. 3

D

o you feel you’re hearing a

lot about ransomware, phishing, and hacking these days? You’re not imagining the increase—these buzzwords are everywhere: news media, compliance reports, technology

PHISHING The primary ways your practice can be compromised are through your IT infrastructure and email. The weakest link in the vulnerability chain is people.

Cybercriminals have gotten quite effective at using malicious email to gain access to Protected Health Information (PHI) and other personal information through what’s called “phishing.” They will send email posing as coming from a trusted source (like a bank, online payment site, or even a social networking site) designed to get you to click a link, call a number or respond with personal information. Every day, criminals steal everything from patient and insurance records to passwords, social security numbers, credit card information and account numbers.

Red Flags

represent more than

Your staff needs to know how to spot phishing; and what to do and what not to do when they do come across it. The Federal Trade Commission’s Consumer Division explains phishing emails and text messages often tell a story to trick you into clicking on a link or opening an attachment.

just the latest media

These emails may:

and trade journals; the list goes on. But they

buzz. They’re real threats. Cybercrimes remain a problem for

● ●

dental and medical

●

professionals with little

● ●

sign of going away anytime soon.

●

●

Say they’ve noticed some suspicious activity or login attempts.

Claim there’s a problem with your account or your payment information.

Say you must confirm some personal information.

Include a fake invoice.

Want you to click on a link to make a payment.

Say you’re eligible to register for a government refund.

Offer a coupon for free stuff.

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147

What happens if someone in your office clicks a link (and your email isn’t secure)?

HOW TO KEEP EMAIL SAFE

Well, you’ve just left the back door unlocked and let a cybercriminal sneak into your business. Once a cybercriminal gets into your system, usually without detection, they have one goal: wreak havoc to get money. They can lock up your entire records system and hold it for ransom, usually requiring payment in Bitcoin. Every day, thousands of attacks are launched with much success. It’s a scenario you don’t want to deal with; and fortunately is preventable.

Use a HIPAA-compliant email service.

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As a dental health provider, confirm every email with any connection to PHI, payments, passwords, or other sensitive information, is being sent through a secure, HIPAA-compliant email service.

•

Check to make sure your secure email service uses its own private network to transmit messages, not the public internet.

•

You’ll also know if your email is fully secure and compliant based on the way email communication is initiated.

If your practice must initiate the first message in an email conversation, then your system is highly secure. I.e., no one can randomly email you or your staff if you didn’t send a secure email to them first. And since cybercriminals can’t reach you, phishing and hacking would not be possible. Once you have that first email interaction with another doctor, pharmacy, patient, etc., your workflow is the same as it would be with any other email.

•

If you’re sending PHI via Google, verify you’re using the paid version, Google Workspace Gmail. Even then, bring in compliance experts to verify that your system meets every federal standard for compliance when sharing PHI electronically.

If you’re using regular Gmail with any modifications, you are most likely gambling with the security and compliance of transmitting PHI. You may want to consider using Gmail and other similar services for sending everything that isn’t PHI or sensitive information. Secure and non-secure emails can often be accessed in the same email interface, which means only one login would be necessary to access all your email accounts.

Educate your staff.

Teach your staff—or bring in an IT Managed Services Provider (MSP) to talk with your office—about the best practices to prevent phishing scams.

•

Learn to identify a suspicious email and report it to your IT or MSP team. (See the “red flags” section.)

•

Most important, never click on buttons/ links, call the listed phone number, or respond to the message, especially with personal information.

•

If you have a moderately-secure email service, replace it with a truly secure, HIPAA-compliant email service, and you’ll significantly decrease the risk of your data being accessed through email.

Following the simple advice in this article can save you headaches and heartbreaks from having PHI stolen or captured and paying a high ransom to get your practice running again.

TDA Perks Program endorses iCoreExchange HIPAA-compliant email. iCoreExchange not only meets or exceeds every compliance and security requirement, it also allows you to attach as many large files as you want to any single email. Learn more about iCoreExchange and how it can speed your workflow and protect patients and your practice. Check out the convenient and compliant service at http://land. icoreconnect.com/TX2 or tdaperks.com (Compliance & Supplies). TDA members receive a substantial discount on iCoreExchange.

Calendar

of events

TMOM 2022 SCHEDULE Houston—April 22-23 Dallas—November 4-5

SMILECON

Houston—October 13-15, 2022 House of Delegates, October 15-18 Due to COVID-19, please check each meeting’s website for up-to-date information related to cancellations or rescheduling.

THE TEXAS DENTAL JOURNAL’S CALENDAR will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed.

Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.

www.tda.org | March 2022

149

ADVERTISING BRIEFS PRACTICE OPPORTUNITIES

us at 512-900-7989 or info@

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#T521): This highly productive,

MCLERRAN & ASSOCIATES: To

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community approximately 30 miles

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from the Austin metro area. Current

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annual revenue is approximately 7

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Texas Dental Journal ADVERTISING BRIEF INFORMATION

figures with net cash flow in excess of 6 figures. The modern facility is located in a retail space and equipped with 6 operatories, CBCT, and paperless charts. The ideal buyer would be 1-2 high producing doctor(s) who are well

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Copy text is due the 20th of the month, 2 months prior to publication (ie, January issue has a due date of November 20.)

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MONTHLY RATES

San Antonio. The office features 5

PRINT: First 30 words—$60 for ADA/TDA members & $100 for non-members. $0.10 each additional word.

ONLINE: $40 per month (no word limit). Online ads are circulated on the 1st business day of each month, however an ad can be placed within 24 business hours for an additional fee of $60.

SUBMISSION Ads must be submitted, and are only accepted, via www.tda.org/Member-Resources/TDAClassified-Ads-Terms. By official TDA resolution, ads may not quote specific incomes or revenues and must be stated in generic terms (ie “$315,000” should be “low-to-mid-6 figures”). Journal editors reserve the right to edit and/or deny copy.

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Texas Dental Journal | Vol 139 | No. 3

ideally located between Austin and operatories, computers throughout, CAD/CAM (Cerec), a CBCT, and all the bells and whistles. The owner is surgically inclined, but that has ultimately led to an abundance of restorative, cosmetic, and ortho treatment being readily available for the incoming buyer. AUSTIN (ID #T532): This turn-key, GD practice in west Austin is located in a approximately 2,500 sq ft, modern facility featuring 6 operatories, digital radiography,

paperless charts, a digital Pano, and a

skill set. The facility is shared with

Cerec Omnicam with milling unit. The

another dentist who has an entirely

practice serves a large FFS/PPO patient

separate patient base. The practice is

base with over 2,700 active patients.

priced at a level that will allow for the

The office offers significant upside

buyer to make immediate upgrades to

potential by way of keeping specialty

the facility or equipment post-sale.

procedures in-house, implementation

EAST TEXAS (ID #H486): Located in

of a marketing/advertising campaign,

a growing east Texas community, this

and the potential to expand office

general practice caters to a dedicated

hours. NORTH OF AUSTIN (ID

multi-generational active patient base.

#T515): GD Practice + Real Estate.

The well-appointed 2,500 sq ft space

Excellent location situated in a

contains 5 fully equipped operatories,

rapidly growing community north

digital pano, plumbed nitrous, and

of Austin. The practice is located in

computers throughout. EAST TEXAS

a free-standing building, contains

(ID #H489): This highly profitable,

4 fully equipped operatories, digital

general dentistry practice and real

X-ray units, and CBCT. This 100%

estate is located in an east Texas

fee-for-service practice boasts a

town. The practice serves a large FFS/

strong hygiene recall program, which

PPO patient base and is on pace to

produces a third of practice revenue

exceed seven figures in revenue in

and a fantastic online reputation.

2021 while maintaining a 45%+ profit

DFW METRO AREA (ID #T529):

margin. The office has 3 fully equipped

100% fee-for-service practice, located

operatories with possible room for

just north of Arlington, is equipped

expansion, digital radiography, and

with 4 computerized operatories and

computers throughout. HOUSTON

paperless charts. The practice has a

(ID #H472): This established,

large active patient base of 1,630 and

boutique practice is located in a highly

averages mid-6 figures. Nearly all

desirable area of central Houston. The

specialty procedures are being referred

practice provides general, implant,

out, which allows immediate growth

and cosmetic dentistry services to

potential for a buyer with an expanded

a 100% FFS patient base and has

www.tda.org | March 2022

151

ADVERTISING BRIEFS an excellent reputation in the local

an excellent hygiene program,

community. The beautiful facility

and further upside via numerous

features high-end finishes/décor, 3

specialty procedures being referred

fully equipped operatories, digital

out. HOUSTON-NORTHEAST (ID

radiography, and a CBCT. HOUSTON,

#H488): FFS/PPO practice + Real

ORTHODONTICS (ID #H480): This

Estate. Growing suburb 45 minutes

productive, FFS orthodontic practice

NE of Houston. 1,800 total patients,

occupies an attractive free-standing

steady flow of new patients, solid

building situated on a high traffic

hygiene recall, and consistent revenue

street in a desirable community in the

of high-6 figures per year. The office

heart of east Texas. The practice has

contains 6 fully equipped operatories,

realized annual revenue of 7 figures

plumbed nitrous, digital X-ays, CBCT,

with exceptional profitability. The

and computers throughout. HOUSTON

office features a 4-chair ortho bay,

(ID #H490): General/cosmetic

2 exam rooms, and digital Pan/Ceph

practice located west of Houston in the

unit. The real estate is also available

highly desirable Memorial area. With

for purchase. HOUSTON-EAST (ID

roughly 40% of the production being

#H483): 100% FFS GD practice

generated from the hygiene program

+ Real Estate. Situated in a 2,200

and numerous specialty procedures

square foot, free standing building

being referred out, there is immediate

with 5 fully equipped operatories.

upside potential to be discovered.

Hygiene production is very healthy and

The office occupies 1,700 sq ft, has 3

the practice has seen 1,700+ active

equipped operatories with room for a

patients in the last 24 months with a

4th, digital radiography, and computers

steady new patient flow. HOUSTON-

throughout. HOUSTON-SOUTHEAST

NORTH (ID #H487): 100% FFS

(ID #H491): 100% FFS practice in a

practice in The Woodlands/Spring area.

growing suburb southeast of Houston.

Modern facility with 4 equipped ops,

The 1,685 sq ft facility contains 3 fully

digital X-ray sensors, an iTero, and

equipped operatories with room for

paperless charts. This practice checks

expansion, digital radiography, and

all of the boxes—strong profitability,

computers throughout. With most

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Texas Dental Journal | Vol 139 | No. 3

ADVERTISING BRIEFS specialty procedures being referred

west of San Antonio. Serves a PPO/

out and little to no marketing, this

FFS patient base, sees approximately

practice offers a tremendous level

30+ new patients per month, and

of upside potential. HOUSTON-

offers consistent annual revenue with

SOUTHWEST (ID #H492): Turn-key,

substantial upside potential through

general dentistry practice located in a

expanding the procedures offered in-

highly desirable suburb in southwest

house. The turn-key office features

Houston. This well-appointed 2,800

3 fully equipped operatories, digital

sq ft office features 6 operatories,

sensors, intra-oral cameras, and a

digital radiography, digital pano, digital

digital pano. SAN ANTONIO (ID

scanner, and paperless charts. The

#T501): Located in a highly sought-

practice serves a large FFS/PPO patient

after area along Loop 1604 in north

base (over 2,500 active patients) and

San Antonio. The practice serves a

features strong hygiene production (40% of total revenue), and solid new patient flow. HOUSTON-NORTH (ID #H493): 100% fee-for-service practice located north of Houston in the high growth area of Spring/ The Woodlands. The office occupies a spacious, standalone office condo and features 5 fully equipped operatories, digital technology, computers

McLerran & Associates is the largest dental practice brokerage firm in Texas.

When it’s time to buy or sell a practice, we’ve got you covered.

P RAC T I C E S AL E S DS O T RAN S ACT I O N S

P RAC T I C E AP P RAISA LS ASSOCIATE PLACEMENT

throughout, and 2 plumbed operatories prepared for future expansion.

Austin

512-900-7989

This is an excellent opportunity to

DFW

214-960-4451

purchase a successful legacy practice

Houston

281-362-1707

poised for growth. SAN ANTONIOWEST (ID #T454): GD Practice + Real Estate. Located in a rural community approximately 75 miles

San Antonio 210-737-0100 South Texas 361-221-1990 Emai l : t ex as@ den t al t r an si t i o n s.co m www.dentaltransitions.com

www.tda.org | March 2022

153

ADVERTISING BRIEFS large PPO/FFS patient base and is

BEAUMONT—GENERAL

located in a spacious office condo

(REFERENCE “BEAUMONT”):

with 6 fully equipped operatories,

Small town practice near a main

digital pano, digital X-rays, and

thoroughfare, 80 miles east of

digital sensors. SAN ANTONIO

Houston. Collections in 7 figures.

(ID #T531): GD practice in a high

Country living, close enough to

visibility retail center along a major

Houston for small commute. Practice

interstate in northwest San Antonio.

in a stand-alone building built in

The office features 4 operatories,

1970. The office is 1,675 sq ft with

digital radiography, CBCT, digital

4 total operatories, 2 operatories

scanner, and paperless charts.

for hygiene and 2 operatories for

Uniquely placed near the intersection

dentistry. Contains, reception area,

of two major interstates in a retail

dentist office, sterilization area, lab

center with a major anchor tenant,

area. Majority of patients are 30 to

this location offers tremendous growth

65 years old. Practice has operated at

opportunities for a buyer to capitalize

this location for over 38 years. Practice

on the surrounding foot traffic and

sees patients about 16 days a month.

visibility. SOUTH TEXAS (ID #T460):

Collection ratio of 100%. The practice

GD Practice and free-standing building,

is a fee-for-service practice. Building is

located in a charming south Texas

owned by dentist and is available for

town. The office is located in a two

sale. Contact Christopher Dunn at 800-

story, free-standing building and has

930-8017 or Christopher@DDRDental.

a spacious layout that includes 6 fully

com. HOUSTON (SHARPSTOWN

equipped operatories (one additional

AREA)—GENERAL (REFERENCE

plumbed for expansion, digital sensors,

“SHARPSTOWN GENERAL”) MOTIVATED

a digital pano, CBCT, and computers

SELLER. Well Established general

throughout. To request more

dentist with high-6 figure gross

information on our listings, please

production. Comprehensive general

register at www.dentaltransitions.

dentistry in the southwest Houston

com or contact us at 512-900-7989 or

area focused on children (Medicaid).

info@dentaltransitions.com.

Very, very high profitability. 1,300 sq

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Texas Dental Journal | Vol 139 | No. 3

ADVERTISING BRIEFS ft, 4 operatories in single building.

Flexible lease options are available for

95% collection ratio. Over 1,200

well-qualified dentists with no down

active patients. 20% Medicaid, 45%

payments and no interest for up to 2

PPO, and 35% fee-for-service. 30% of

years. Don’t waste time and money on

patients younger than 30. Office open

buildouts when you can have a great

6 days a week and accepts Medicaid.

practice today. Turnkey dental offices

Contact Christopher Dunn at 800-

for sale in the Dallas/Fort Worth metro

930-8017 or Christopher@DDRDental.

and surrounding areas, the offices

com. HOUSTON (BAYTOWN AREA)—

are strategically located in areas for

GENERAL (REFERENCE “BAYTOWN

high production with ample parking.

GENERAL”) MOTIVATED SELLER.

Locations are ideal for emergency

Well established general practice

dental services, Medicaid, insurance

with mid-6 figure gross production.

and FFS. Can be sold separately or as

Comprehensive general dentistry in

a package. Requirements dentists need

Baytown on the east side of Houston.

to have at least 2 years of experience

Great opportunity for growth! 1,400

in private practice/corporate dentistry;

sq ft, 4 operatories in single story

credit and background check. For

building. 100% collection ratio. 100%

more information, please email

fee-for-service. Practice focuses on

Txpracticesales@gmail.com or call/text

restorative, cosmetic and implant

214-995-0806.

dental procedures. Office open 3-1/2 days a week. Practice area is owned

FORT WORTH: Practice for sale in the

by dentist and is available for sale.

fast growing southwest area. Average

Contact Christopher Dunn at 800-930-

gross; 6 operatories; Excellent lease.

8017 or Christopher@DDRDental.com.

Seller is relocating. Need to move quickly on this one. DFW 214-503-

DALLAS: Don’t waste time and money

9696. WATS 800-583-7765.

on buildouts when you can have a great practice today. Great opportunity to start your dental practice without having to pay a big loan and interest.

www.tda.org | March 2022

155

ADVERTISING BRIEFS HOUSTON AREA: Several acquisition

reference “Lufkin General or TX#540”.

opportunities in the greater

HOUSTON—GENERAL (SHARPSTOWN)

Houston area. General, ortho, pedo

Well established general dentist

practices available for sale. Visit

with high-6 figure gross production.

lonestarpracticesales.com or email

Comprehensive general dentistry in

houstondentist2019@gmail.com.

the southwest Houston area focused on children (Medicaid). Very, very

HOUSTON, COLLEGE STATION, AND

high profitability. 1,300 sq ft, 4

LUFKIN (DDR DENTAL Listings).

operatories in single building. 95%

(See also AUSTIN for other DDR Dental

collection ratio. Over 1,200 active

listings and visit www.DDRDental.

patients. 20% Medicaid, 45% PPO,

com for full details. LUFKIN—GENERAL

and 35% fee for service. 30% of

practice on a high visibility outer

patients younger than 30. Office open

loop highway near mall, hospital

6 days a week and accepts Medicaid.

and mature neighborhoods. Located

Contact Chrissy Dunn at 800-930-

within a beautiful single-story, free-

8017 or chrissy@ddrdental.com

standing building, built in 1996 and

and reference “Sharpstown General

is also available for purchase. Natural

or TX#548”. HOUSTON—GENERAL

light from large windows within 2,300

(PEARLAND AREA) GENERAL Located

sq ft with 4 operatories (2 hygiene

in southeast Houston near Beltway

and 2 dental). Includes a reception

8. It is in a freestanding building.

area, dentist office, a sterilization

Dentist has ownership in the building

area, lab area, and break room. All

and would like to sell the ownership

operatories fully equipped. Does not

in the building with the practice. One

have a pano but does have digital

office currently in use by seller. A 60

X-ray. Production is 50% FFS and 50%

percent of patients age 31 to 80 and

PPO (no Medicaid), with collection ratio

20% 80 and above. Four operatories

above 95%. Providing general dental

in use, plumbed for 5 operatories.

and cosmetic procedures, producing

digital pano and digital X-ray. Contact

mid-6 figure gross collections. Contact

Christopher Dunn at 800-930-8017

Christopher Dunn at 800-930-8017

or christopher@ddrdental.com and

or Christopher@DDRDental.com and

reference “Pearland General or

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Texas Dental Journal | Vol 139 | No. 3

ADVERTISING BRIEFS TX#538”. HOUSTON—PEDIATRIC

consultation room, 2 offices, a

(NORTH HOUSTON) This practice

breakroom, and storage. This

is located in a highly sought-after

FFS practice collects in the high-6

upscale neighborhood. It is on a major

figures annually. Current dentist will

thoroughfare with high visibility in a

participate in a 3- to 5-year transition.

strip shopping center. The practice has

Contact 713-781-3599 or email

three operatories for hygiene and two

bkkpallen@gmail.com.

for dentistry. Nitrous is plumbed for all operatories. The practice has digital

KATY: Now is the time to join Grand

X-rays and is fully computerized. The

Lakes Dental Group and Orthodontics.

practice was completely renovated

You will have opportunities to

in 2018. The practice is only open

learn new skills from our team of

3-1/2 days per week. Contact

experienced professionals. If you’re

Christopher Dunn at 800-930-8017

ready to take your career to the next

or christopher@ddrdental.com and

level and gain valuable experience,

reference “North Houston or TX#562”.

apply today! You’ve invested the time

WEST HOUSTON—MOTIVATED SELLER.

to become a great dentist, now let

Medicaid practice with production

us help you take your career further

over 6 figures. Three operatories in

with more opportunity, excellent

1,200 sq ft in a strip shopping center.

clinical leadership and one of the best

Equipment is within 10 years of age.

practice models in modern dentistry.

Has a pano and digital X-ray. Great

In working with our practice you will

location. If interested contact chrissy@

have the autonomy to provide your

ddrdental.com. Reference “West

patients the care they deserve. In

Houston General or TX#559”.

addition, you’ll enjoy the opportunity to earn excellent income and have

HOUSTON: Established general

great work-life balance without the

practice located in the Galleria/

worries of running a practice. You

Memorial Villages area of Houston

became a dentist to provide excellent

for sale. The 4,000 sq ft leased

patient care and have a career that will

space has 8 operatories, 2 dental

serve you for a lifetime. With us, you

labs, 2 sterilization areas, a private

will have a balanced lifestyle, fantastic www.tda.org | March 2022

157

ADVERTISING BRIEFS income opportunities, and you’ll

contact a recruiter anytime. We’d love

work for an office that cares about

to chat, get to know you and share

their people, their patients and their

more about us. Pacific Dental Services

community. Our practice is an office

is an equal opportunity employer and

supported by Pacific Dental Services

does not discriminate against any

(PDS), which means you won’t have to

employee or applicant for employment

spend your career navigating practice

based on race, color, religion, national

administration. Instead, you’ll focus

origin, age, gender, sex, ancestry,

on your patients and your well-being.

citizenship status, mental or physical

Add on excellent benefits, including

disability, genetic information, sexual

malpractice insurance, medical, dental

orientation, veteran status, or military

and vision insurance, retirement plans

status. Apply here:http://www.

and much more and you’ll feel well

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taken care of throughout your career.

PI106822492.

The average full-time PDS-supported associate dentist earns low-6 figures

WATSON BROWN PRACTICES FOR

in their first year. The average income

SALE: Practices for sale in Texas

for a PDS-supported owner dentist,

and surrounding states, For more

whose practice has been open at

information and current listings please

least 2 years, is mid-6 figures. As

visit our website at www.adstexas.com

an associate dentist, you will receive

or call us at 469-222-3200 to speak

ongoing training to keep you informed

with Frank or Jeremy.

and utilizing the latest technologies and dentistry practices. If you are interested in a path to ownership, our

INTERIM SERVICES

proven model will provide you with the training needed to become an owner

HAVE MIRROR AND EXPLORER,

of your own office. PDS is one of the

WILL TRAVEL: Sick leave, maternity

fastest growing companies in the US

leave, vacation, or death, I will cover

which means we will need excellent

your general or pediatric practice. Call

dentists like you to continue to lead

Robert Zoch, DDS, MAGD, at 512-517-

our growth in the future. Apply now or

2826 or drzoch@yahoo.com.

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Texas Dental Journal | Vol 139 | No. 3

YOUR PATIENTS TRUST YOU.

WHO CAN YOU TRUST?

ADVERTISERS AFTCO........................................................... 133 Anesthesia Education & Safety Foundation... 106 DentalPost..................................................... 130 E-VAC, Inc..................................................... 132 Henry Schein Financial Services.................... 118

If you or a dental colleague

JKJ Pathology................................................ 113

are experiencing impairment

Law Offices of Hanna & Anderton..................... 132

due to substance use or mental illness, The Professional

Linda C. Niessen Geriatric Dentistry Symposium................................................... 129

Recovery Network is here

McLerran & Associates.................................. 153

to provide support and an opportunity for confidential recovery.

MedPro Group............................................... 119 Professional Recovery Network..................... 159 SmileCon 2022.............................................. 131 Southwest Sedation Education...................... 133 TDA Perks.............................. Inside Front Cover Texas Health Steps........................................ 103 UTHealth San Antonio Pathology Lab............ 118

PRN Helpline (800) 727-5152

Visit us online www.txprn.com

UTHealth Houston Pathology......................... 130 Watson Brown Practice Sales & Appraisals.... 107

www.tda.org | March 2022

159

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